Intended for healthcare professionals

Practice Uncertainties

Which operation is most effective for complete rectal prolapse?

BMJ 2019; 366 doi: (Published 01 August 2019) Cite this as: BMJ 2019;366:l4723
  1. Stella Maye Dilke, research fellow1 2,
  2. Claire Becker, general practitioner3,
  3. Phillip James Tozer, consultant colorectal surgeon2,
  4. Carolynne Vaizey, consultant colorectal surgeon1
  1. 1St Mark's Hospital, Harrow, London, UK
  2. 2Imperial College Faculty of Medicine, St Mark’s Hospital, London
  3. 3Spring House Medical Centre, Welwyn Garden City, UK
  1. Correspondence to: S M Dilke stella.dilke{at}

What you need to know

  • Surgery, through the abdomen or perineum, is the definitive treatment to repair complete rectal prolapse

  • A range of surgical techniques are used, but there is insufficient evidence to determine whether one technique is better than others in terms of rates of recurrence and complications such as constipation and incontinence

  • Patient preferences and general fitness for surgery are useful to guide decision making

Rectal prolapse affects about 2.5 per 100 000 people each year in the United Kingdom.1 It is more common in women.2 Risk factors include multiple deliveries, straining, anorexia, traumatic vaginal delivery, and old age.3 Protrusion of the rectum through the anal canal can be distressing for the patient, causing discomfort and embarrassment. Complications include bleeding, constipation, incontinence, rectal ulcers, and, rarely, rectal ischaemia, which is an emergency.

Complete (full thickness) rectal prolapse involves protrusion containing all the layers of the rectal wall through the anus (fig 1). A mucosal prolapse occurs when mucosa alone protrudes through the anus. Internal intussusception is a prolapse of the rectum into the distal rectum or anal canal but without protrusion outside the anus.

Fig 1

Full thickness rectal prolapse (reproduced with permission of Société Nationale Française de Colo-Proctologie)

Surgery is the definitive treatment and can provide complete resolution of full thickness rectal prolapse.4 Some patients, however, experience recurrence and complications such as constipation and faecal incontinence and may require further surgery.3 A minority of patients prefer symptom control, or are unfit for surgery, and are treated with laxatives and manual reduction.

In this article we focus on surgical management of full thickness rectal prolapse. There are a range of surgical techniques available (box 1),23 but there is no consensus on which is the most effective.5 Traditionally, the open abdominal procedure was reserved for younger, fitter patients, …

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